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RD33B76  Surgical  suggestions 


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SURGICAL  SUGGESTIONS. 


SURGICAL  SUGGESTIONS 

PRACTICAL  BREVITIES  IN  DIAGNOSIS 
AND  TREATMENT 


WALTER  M.  BRICKNER,  M.D. 

Chief  of  Surgical  Department,  Mount  Sinai  Hospital  Dispensary ; 

Editor-in-Chief,  American  fournal  of  Surgery, 

New  York, 


ELI  MOSCHCOWITZ,  M.D. 

Assistant  Physician,  Mount  Sinai  Hospital  Dispensary  ; 

Editorial  Associate,  American  fournal  of  Surgery, 

New  York. 


NEW  YORK  : 

Surgery  Publishing  Company 

92  WILLIAM  street 

1906 


Copyright,  1906,  by  Surgery  Publishing  Company 


PREFACE 

The  "  Surgical  Suggestions  "  published  during  the 
past  year  in  the  successive  issues  of  the  American 
Journal  of  Surgery  have  been  extensively  quoted 
in  medical  journals  throughout  the  United  States 
and  Canada.  This  has  suggested  to  us  that  their 
arrangement  in  logical  order,  and  in  a  concise  form , 
might  prove  of  value. 

These  practical  brevities  make  no  pretensions  to 
completeness.  They  are  merely  observations  taken 
here  and  there  from  our  own  surgical  experiences. 

W.  M.  B. 
E.  M. 


4S7SKSO 


HEAD. 


SURGICAL  SUGGESTIONS. 


In  cases  of  head  traumata,   bleeding  from 
the  mouth  or  nose  does  not  necessarily  mean     *-ranium« 
that  the  case  is  one  of  fracture  at  the  base. 
The  hemorrhage  may  be   entirely   due   to   a 
localized  injury. 

In  exploring  for  tumors  of  the  brain,  the 
best  guide  for  determining  an  isolated  hard- 
ness is  the  finger;  the  use  of  a  needle  is  very 
deceptive. 

Severe  pain  in  the  orbit  or  even  in  the 
eye  itself  should  make  one  think  of  frontal 
sinus  infection,  especially  if  there  is,  or  re- 
cently has  been,  a  nasal  discharge.  Marked 
localized  tenderness  will  soon  confirm  the 
suspicion,  if  the  disease  exist. 

A  persistent,  chronic  discharge  from  the 
nose  should  lead  one  to  suspect  chronic  dis- 
ease of  the  frontal  or  other  accessory  sinus. 

Frontal  sinus  suppuration  rarely  requires 
a  disfiguring  operation  for  its  relief.  It  can 
usually  be  satisfactorily  dealt  with  through 
an  opening  in  the  line  of  the  eyebrow. 


HEAD. 


In  chronic  osteomyelitis  of  the  jaw  it  is 
better  to  wait  months  for  a  sequestrum  to 
form  than  to  operate  a  dozen  times  for  the 
removal  of  necrosed  bone. 


Plouth  and 
Throat. 


Before  operating  for  pharyngeal  adenoids  or 
hypertrophied  tonsils  make  sure  that  these  are 
not  merely  an  expression  of  status  lymphati- 
cus.  If  they  are,  do  not  employ  an  anes- 
thetic. Also  determine  whether  the  patient 
is  a  hemophiliac.  If  he  is,  do  not  operate  at 
all. 


When  opening  a  retropharyngeal  or  peri- 
tonsillar abscess  in  a  small  child,  by  the  buccal 
route,  have  the  head  dependent  and  instru- 
ments at  hand  for  tracheotomy.  These  in- 
struments are  needed  but  rarely,  but  then 
urgently. 

It  is  wrong  to  perform  any  radical  opera- 
tion for  an  ulcer  of  the  tongue  without  pre- 
liminary microscopical  examination.  Clinical 
symptoms,  no  matter  how  typical,  are  often 
misleading. 


When  a  patient  complains  of  dysphagia, 
do  not  neglect  to  examine  the  pericardium 
for  effusion. 


HEAD. 


A  furuncle  deeply  situated  in  the  external 
auditory  canal  gives  signs  that  may  be  mis-      Ear« 
taken  for  mastoiditis.     Great  pain  when  the 
concha  is  moved  about,  will  serve  to  differen- 
tiate it  from  the  latter. 

Severe  and  repeated  headaches  may  be 
due  to  the  unsuspected  presence  of  otitis 
media,  with  or  without  mastoiditis. 

In  cases  of  unaccountable  fever,  especially 
in  children,  never  fail  to  examine  the  ear. 

Tinnitus  aurium,  present  only  in  the  re- 
cumbent posture,  is  suggestive  of  aneurism  of 
one  of  the  posterior  cerebral  vessels. 

The  history  of  a  discharge  from  an  ear  ap- 
pearing a  few  days  to  a  few  weeks  after  the 
beginning  of  a  slowly  developing  deafness 
in  that  ear,  unaccompanied  at  any  time  by 
pain,  is  suspicious  of  tuberculous  otitis  media. 

A  bean-shaped  pulsating  swelling  just  be- 
low the  mastoid  apex,  in  cases  of  mastoiditis, 
may  be  only  a  lymphatic  gland,  but  it  may 
also  be  a  thrombosed  jugular  vein.  Its  nature 
should  therefore  be  determined  before  the 
operation  is  concluded. 


During  mastoid  operations  always  sever 
with  scissors  any  fragment  of  tissue  attached 
to  a  bit  of  bone  loosened  with  the  chisel  or 
rongeur,  before  removing  it.  The  tearing  out 
of  a  fiber  of  the  sterno-mastoid  muscle,  for 
example,  will  open  a  channel  of  infection  in 
the  neck. 

If  the  zygomatic  cells  are  thoroughly  laid 
open,  one  frequent  cause  of  persistent  sup- 
puration requiring  secondary  mastoid  opera- 
tion, may  be  avoided. 

In  seeking  a  cause  for  torticollis,  don't  fail 
to  examine  the  teeth. 

Persistent  pain  in  an  arm  may  be  due  to 
the  presence  of  a  "cervical  rib." 

Avoid  the  use  of  peroxid  of  hydrogen  in 
wounds  of  the  neck.  It  is  too  apt  to  dissect 
up  the  loose  cellular  planes.  The  same  warn- 
ing applies  in  many  cases  of  cellulitis  of  the 
hand  or  foot. 

Do  not  empty  a  thyro-glossal  cyst  by  as- 
piration before  extirpating  it.  It  is  well  to 
inject  the  cavity  with  a  methylene  blue  solu- 
tion first,  in  order  to  make  sure  that  all  parts 


10 


of  the  cyst  wall  will  be  extirpated.  An- 
other method  is  to  first  empty  the  cyst  and  then 
fill  it  with  paraffin. 

Hard  subcutaneous  tumors  of  the  upper 
third  of  the  neck,  with  signs  of  malignancy, 
are  often  epitheliomata  arising  from  branchial 
clefts. 

The  best  site  for  an  urgent  tracheotomy  is 
through  the  crico-thyroid  membrane.  To 
hold  the  opening  apart  a  couple  of  hair  pins 
bent  at  the  end  may  be  used  as  retractors. 

In  the  performance  of  high  tracheotomy  a 
great  deal  of  room  can  be  gained  by  dividing 
transversely  the  fascia  that  extends  upward 
from  the  thyroid. 

The  greatest  immediate  danger  after  a 
tracheotomy  is  the  possibility  of  a  subsequent 
pneumonia.  This  can,  in  a  large  measure, 
be  obviated  by  filtering  the  inspired  air 
through  a  soft  sponge  saturated  with  warm 
one  per  cent,  phenol  solution. 

Repeated  attacks  of  coughing  after  trache- 
otomy may  mean  irritation  of  the  posterior 
wall  of  the  trachea  by  the  tube;  change  the 
length  or  shape  of  the  canula. 


ii 


BREAST. 


THORAX. 


A  "tumor"  of  the  breast  occasionally 
proves  to  be  only  a  chronic  abscess.  It  has 
happened  that  a  breast  amputated  for  carci- 
noma has  been  found  to  be  the  seat  of  old  ab- 
scesses only. 

In  the  presence  of  a  breast  infection  that 
fails  to  heal  within  a  reasonable  time  after 
appropriate  incision  and  dressings,  it  is  well 
to  think  of  local  tuberculosis. 

Do  not  be  too  hasty  in  making  a  diag- 
nosis of  intercostal  neuralgia.  With  the  ex- 
ception of  pulmonary  and  pleural  conditions, 
ulcer  of  the  stomach  simulates  intercostal  neu- 
ralgia more  frequently  than  any  other  lesion. 


In  strapping  the  chest  for  fractured  rib, 
two  points  should  be  particularly  noted: 
I.  The  straps  should  pass  well  beyond  the 
median  line.  2.  They  should  be  applied  in 
full  expiration.  One  or  two  straps  passed 
over  the  shoulder  help  much  to  secure  im- 
mobilization. 

It  is  remarkable  how  frequently  a  puru- 
lent pericarditis  may  exist  without  causing 
many  or  severe  symptoms.  Never  neglect 
an  examination  of  the  cardiac  area,  there- 
fore, in  cases  of  suspected  sepsis. 


12 


THORAX. 


In  aspirating  the  chest,  see  to  it  that  the 
syringe  is  in  good  condition  before  inserting 
the  needle.  Never  apply  the  syringe  to  the 
needle  after  the  latter  'has  been  inserted;  a 
severe  pneumothorax  may  result.  If  the 
syringe  is  found  to  be  out  of  order  while 
the  aspiration  is  being  done,  withdraw  the 
needle  also  and  reinsert. 


There  is  one  point  that  must  always  be 
thought  of  when  pus  has  been  aspirated  after 
an  exploratory  puncture  for  either  suspected 
empyema  or  liver  abscess, — to  make  sure  that 
the  "pus"  does  not  come  from  a  bronchus. 
This  can  be  determined,  as  a  rule,  by  micro- 
scopical examination  of  the  aspirated  fluid. 

Very  extensive  and  rapidly  spreading  sub- 
cutaneous infections  may  result  after  an  aspi- 
ration of  a  foul-smelling  empyema.  It  is 
therefore  wise  to  always  operate  over  the  site 
of  aspiration,  and  especially  to  see  that  the 
puncture  wound  is  well  drained. 


When  operating  for  empyema  thoracis  it  is 
a  good  rule  to  aspirate  again  when  the  pleura 
is  exposed  and  before  it  is  incised.  This  may 
save  some  embarrassment. 


13 


THORAA. 


The  shock  of  evacuating  an  empyema  tho- 
racis may  be  largely  avoided  by  making  but 
a  small  opening  in  the  pleura  (after  resecting 
the  rib)  and  applying  at  once  several  thick- 
nesses of  gauze.  At  the  next  dressing  much 
or  most  of  the  pus  will  be  found  to  have  es- 
caped into  the  gauze,  and  the  pleural  wound 
may  then  be  enlarged  without  producing 
shock. 


ABDOHEN. 


It  is  surprising  how  much  information  can 
be  derived  by  abdominal  palpation  conducted 
with  the  patient  in  a  hot  bath,  the  tempera- 
ture of  the  water  being  gradually  raised  to 
1 05  degrees  F.  It  usually  secures  as  much 
relaxation  as  does  the  administration  of  an 
anesthetic,  sometimes  even  more.  In  addition 
to  the  avoidance  of  the  dangers  and  the  dis- 
agreeable features  of  narcosis,  it  has  the 
important  advantage  that  the  patient  is  able 
to  call  the  examiner's  attention  to  sen- 
sitive areas. 

Enlargement  of  the  veins  at  the  side  of  the 
abdomen  is  indicative  of  obstruction  to  the 
flow  of  blood  in  the  inferior  vena  cava;  dis- 
tention of  veins  about  the  umbilicus  sug- 
gests obstruction  in  the  portal  circulation. 
The  former  may  be  associated  with  varices  of 
the  lower  extremities,  the  latter  with  hemorr- 
hoids. 

U 


ABDOMEN. 


Steady  loss  of  weight  without  other  de- 
monstrable cause  should  lead  the  physician 
to  look  for  a  possible  malignant  visceral  neo- 
plasm. Persistent  "indigestion"  due  to 
some  condition  not  positively  ascertained, 
should  be  submitted  to  surgical  diagnosis. 

Unless  some  other  cause  is  evident  don't 
fail  to  examine  for  signs  of  tabes  when  an 
adult  complains  of  pains  about  the  waist,  in 
the  back  or  in  the  lower  extremities. 

In  all  cases  of  acute  abdominal  pain,  never 
fail  to  examine  the  lungs  and  gums.  The  on- 
set of  pneumonia  or  pleurisy  frequently  close- 
ly simulates  acute  appendicitis;  lead  colic 
may  simulate  almost  any  painful  abdominal 
condition. 

Do  not  ligate  tumors  of  the  navel  without 
making  sure  that  the  intestine  is  not  included 
within  the  ligature. 

Eczema  of  the  umbilicus  is  sometimes 
merely  the  expression  of  an  infected  dermoid 
cyst  at  that  site. 

Catheterization  sometimes  makes  the  evi- 
dences of  "  appendicitis  "  or  abdominal  tumor  " 


15 


ABDOMEN. 


Bile  Tract. 


vanish  with  the  escape  of    the   urine    from    a 
distended  bladder. 

In  perfoming  paracentesis  in  the  median 
line  for  abdominal  fluid,  be  sure  that  the* 
bladder  is  empty.  When  it  is  necessary  to 
perform  paracentesis  in  the  lateral  part  of  the 
abdomen,  be  careful  to  avoid  the  deep  epi- 
gastric artery. 

Gradually  increasing  jaundice  without 
previous  history  of  pain,  or  with  a  history  of 
very  slight  pain,  is  very  suggestive  of  malig- 
nant disease. 

Examine  the  rectum  in  all  cases  of  tumor 
of  the  liver.  Likewise,  before  operating  for 
cancer  of  the  rectum  examine  the  liver  for 
metastasis. 

In  the  progress  of  a  cholecystectomy,  if  a 
stone  slips  away  after  cutting  through  the 
cystic  duct,  and  cannot  be  found,  no  great 
anxiety  need  be  felt,  for  the  stone  usually 
comes  away  spontaneously  in  the  subsequent 
discharge. 

Great  pain  following  any  operation  upon 
the  biliary  tract  should  always   lead  one  to 


16 


ABDOMEN. 


suspect  leakage  of  bile  into  Morrison's  space. 
If  such  should  be  found  to  be  the  case  insert  a 
drainage  tube. 

When  operating  for  cholelithiasis,  don't 
fail  to  examine  the  hepatic  duct. 

When  palpating  the  common  bile  duct 
for  stone,  make  sure  that  a  suspected  calcu- 
lus is  not  a  gland. 

Children  who  complain  frequently  of  pain     stomach. 
in  the  stomach  should  be  examined  for  evi- 
dence    of    beginning     Pott's    disease.     Such 
cases  treated  before  the  development  of  curva- 
ture usually  yield  very  satisfactory  results. 

In  all  cases  of  recurrent  vomiting  examine 
the  midline  of  the  abdomen  for  a  small  epi- 
gastric hernia. 

It  is  a  peculiar  fact  that  post-operative 
prolapse  through  the  epigastric  wound  oc- 
curs frequently  in  operations  for  malignant 
disease  of  the  stomach.  Such  wound  there- 
fore should  be  closed  with  more  than  usual 
firmness  and  all  possible  precautions  should 
be  taken  to  guard  against  post-operative  vom- 
iting. 

17 


ABDONEN. 


In  a  patient  with  spondylitis,  symptoms 
simulating  acute  peritonitis  may  be  due  to 
acute  dilatation  of  the  stomach. 

A  reasonable  suspicion  of  the  presence  of 
a  cancer  in  the  stomach  or  intestine  is  suffi- 
cient indication  for  explorative  operation. 

Do  not  be  too  sure  that  a  mass  in  the  region 
of  the  pylorus  is  a  carcinoma.  In  some  cases 
the  infiltration  around  a  chronic  ulcer  is  very 
extensive  and  may  simulate  the  feel  of  a  new 
growth. 

If  a  patient  begins  to  vomit  long  after  a 
radical  operation  for  carcinoma  of  the 
stomach,  do  not  jump  to  the  conclusion 
that  the  cause  is  a  local  recurrence.  It  may 
be  a  metastasis  in  the  brain. 

Intestines.  In  the  presence  of  anemia  or  of  faintness, 
without  other  apparent  cause,  inquire  con- 
cerning the  passage  of  black  stools.  The 
condition  may  result  from  hemorrhages  due 
to  an  ulcer  or  neoplasm  of  the  small  intes- 
tine. 

In  typhoid  fever  spontaneous  rupture  of 
the  spleen  may  simulate  intestinal  perforation. 

18 


ABDOMEN, 


At  the  onset  of  an  attack  of  acute  appen- 
dicitis the  pain  is  usually  referred  to  the  gas- 
tric region. 

The  twisting  of  the  pedicle  of  a  small 
ovarian  cyst  may  simulate  both  the  symp- 
toms and  signs  of  attacks  of  appendicitis. 

Simple  or  multiple  enterostomy,  usually 
with  prompt  suture  of  the  opening,  is  many 
times  a  life-saving  operation  in  the  presence 
of  intestinal  paresis,  as  from  general  periton- 
itis. 

Attacks  of  abdominal  pain  preceded  by 
"rumbling"  of  the  bowels  is  suggestive  of 
some  obstructive  condition. 

A  passage  of  gas  or  even  of  a  small 
amount  of  feces,  after  an  enema,  does  not 
gainsay  the  presence  of  intestinal  obstruction. 

In  an  acute  condition  simulating  intesti- 
nal obstruction,  if  a  large  mass  can  be  felt  in 
the  abdomen,  think  of  omental  torsion. 

An  attack  of  acute  intestinal  obstruction, 
with  passage  of  blood,  and  in  the  presence 
of  a  cardiac  lesion,  is  suggestive  of  throm- 
bosis of  a  mesenteric  vessel. 


19 


ABDOHEN. 

Every  case  of  intestinal  obstruction  of  ob- 
scure origin  should  be  inquired  into  closely 
with  reference  to  a  previous  history  of  chole- 
lithiasis. If  a  definite  history  of  this  is  ob- 
tained, it  is  well  to  suspect  obstruction  by  a 
gall-stone. 

When  operating  for  volvulus  of  the  large 
intestine,  insert  a  rectal  tube  as  high  up  as 
possible  before  attempting  the  reduction. 
The  volvulus  will  quickly  collapse  and  the 
necessity  for  evisceration  will  thus  be  avoid- 
ed. 

When  reducing  an  intussusception  don't 
pull  on  the  intussusceptum  but  push  on  the 
intussuscipiens. 

Don't  fail  to  make  a  digital  rectal  exami- 
RECTUM.  nation  in  cases  of  appendicitis  and  in  all  ail- 

ments when  the  diagnosis  is  obscure.  Nor 
should  it  ever  be  omitted  before  an  operation 
upon  anal  disorders.  It  may  save  the  em- 
barrassment of  a  subsequent  discovery  that 
a  patient's  hemorrhoids,  for  example,  were 
but  an  expression  of  a  carcinoma  higher  up 
in  the  rectum. 

A  radical  operation  for  hemorrhoids 
should  not  be  undertaken  until  the  etiology 


20 


BECTUM. 


of  the  piles  has  been  determined.  Some- 
times the  cause  is  an  obstruction  in  the  portal 
circulation  due  to  hepatic  disease.  Per 
contra,  abcess  of  the  liver  may  be  due  to  in- 
fection from  a  hemorrhoid  operation  perform- 
ed even  some  months  before. 

A  skin-lined  sinus  opening  between  the 
coccyx  and  the  anus,  when  not  very  short, 
usually  leads  to  a  dermoid  cyst  situated 
close  to  the  coccyx.  Frequently  loose  hairt> 
from  the  dermoid  may  be  found  in  the  sinus. 

Although  the  anal  reflex  requires  profound 
anesthesia  to  abolish,  chloroform  or  ether  is 
not  always  needed  in  order  to  divulse  the 
sphincter  ani.  This  may  be  accomplished 
painlessly,  and  usually  with  entire  satisfac- 
tion, under  ethyl  chlorid  or  nitrous  oxid  nar- 
cosis if,  especially,  an  opium  suppository  is 
introduced  a  half-hour  beforehand,  and  a 
pledget  of  cotton  wet  in  cocain  solution  is 
applied  just  before  the  operation. 

After  an  operation  for  hemorrhoids  it  is 
desirable  to  insert  into  the  rectum  a  tampon 
canula,  made  by  smearing  with  vaselin  gauze 
layers  wrapped  about  a  piece  of  rub- 
ber tubing,  about  three  inches  long  and  trans- 
fixed at  its  distal  extremity  with  a  large  safety 


21 


KECTUN. 


pin.  The  tampon  canula  prevents  oozing 
by  its  gentle  pressure,  allows  any  consider- 
able hemorrhage  to  show  itself  externally, 
makes  the  escape  of  flatus  painless  and  the 
introduction  of  an  oil  enema  easy. 

After  operations  upon  the  rectum,  especially 
after  those  involving  divulsion  of  the  sphinc- 
ter ani,  voluntary  urination  is  apt  to  be  in- 
hibited for  a  day  or  more.  This  is  especi- 
ally the  case  when  stretching  is  done  in  a  sag- 
ittal direction,  i.e.,  towards  the  urethra  and 
the  coccyx.  It  may  save  catheterization, 
therefore,  if  the  stretching  is  done  only  later- 
ally, i.e.,  towards  the  tubera  ischii. 

When  removing  hemorrhoids  much  after- 
pain  may  be  obviated  by  making  radiating 
nicks  in  the  skin  margin  of  the  anus. 

Prolapse  of  the  rectum  in  children  usual- 
ly yields  to  treatment  by  strapping  the  nates 
together  with  adhesive  plaster,  if  carried  out 
intelligently  and  persistently,  for  several 
weeks  or  months.  The  child  should  be 
obliged  to  defecate  in  the  recumbent  pos- 
ture and  while  the  strap  is  on.  After  de- 
fecation the  strap  is  removed,  the  parts 
cleansed  and  a  fresh  strap  applied,  all  while 
the  child  is  recumbent. 


22 


GENITCMJRINARY  TRACT. 


It  is  not  sufficiently  established  that  the 
character  of  the  crystals  found  in  the  urine  in- 
dicates the  presence  or  identity  of  lithiasis  in  Ureter. 
the  urinary  tract.  When  cystin  crystals  are 
constantly  found  in  the  sediment,  however,  if 
symptoms  of  lithiasis  are  present,  the  stone  is 
probably  made  up  of  cystin. 

A  point  worth  remembering  in  the  diag- 
nosis of  nephrolithiasis  is  that  red  blood  cells 
are  almost  always  found  in  the  centrifugalized 
sediment  in  the  urine  even  in  the  interval  be- 
tween attacks  of  colic. 

In  a  very  acid  urine  red  blood  cells  may  be 
disintegrated  and  appear  under  the  microscope 
as  an  amorphous  material.  When  it  is  im- 
portant to  determine  the  presence  or  absence 
of  blood  in  the  urine  it  is  sometimes  neces- 
sary, therefore,  to  resort  to  a  chemical  test, 
e.  g.,  that  with  guaiac  resin. 

A  radiographic  shadow  simulating  that 
of  a  urinary  calculus  may  be  produced  by  an 
atheromatous  plaque,  as,  for  example,  in 
the  internal  iliac  artery,  by  a  phlebolith,  or 
by  a  calcareous  gland. 

Attacks  of  abdominal  pain  associated  only 
with    intestinal    symptoms,    may    nevertheless 

23 


GENITCMJRINARy  TRACT. 


be  due  to  a  renal  or  ureteral  calculus,  even 
though,  in  addition,  a  tender  area  may  be 
palpated  at  a  point  more  or  less  remote  from 
the  kidney  regions. 

The  perinephric  space  is  a  frequent  site  of 
metastatic  inflammation  after  furunculosis  or 
other  septic  infection. 

If  possible,  always  tie  each  component  of  a 
kidney  pedicle  separately,  not  en  masse. 

If  a  stump  ligature,  e.  g.,  of  the  renal  pe- 
dicle, is  slow  to  come  away,  the  process  may 
be  hastened  by  fastening  it  taut  to  a  piece 
of  rubber  tubing  stretched  across  the  wound. 

If  pus  persists  in  the  urine  after  the  extir- 
pation of  a  kidney  for  suppurative  disease, 
it  often  means  that  the  ureter  is  involved  and 
will  require  subsequent  extirpation. 

When  operating  upon  the  ureter  for  cal- 
culus or  stricture,  avoid  undue  manipulation; 
it  is  important  to  prevent  detachment  of  the 
ureter  from  its  bed,  if  possible. 

Pyuria  without  symptoms  is  suspicious  of 
an  early  tuberculosis  of  the  urinary  tract. 


24 


GENITOURINARY  TRACT. 

Most  cases  of  sudden,  unexpected  hemor- 
rhage from  the  urethra,  are  due  to  malignant 
disease,  but  it  is  well  to  remember  that  there 
are  cases  of  genito-unnary  tuberculosis  in 
which  such  a  hemorrhage  is  the  first  symp- 
tom. 

The  examination  for  tubercle  bacilli  in  the 
urine  by  the  ordinary  method  of  staining,  is 
not  decisive  by  any  means,  even  if  the  blad- 
der has  been  catheterized  and  differential 
stains  for  smegma  bacilli  have  been  employed. 
Numerous  examinations  with  the  aid  of  these 
procedures  must  be  made,  and  even  then  the 
diagnosis  is  only  a  presumptive  one.  The 
only  sure  test  is  by  injecting  a  large  quantity 
of  the  sediment  into  a  guinea-pig. 

Before  excluding  glycosuria  examine  both 
morning  and  evening  specimens  of  the  urine. 

Involuntary  urination   very  often   means   a 
distended  bladder,  and  in  old  men  it  should      Bladder. 
at  once  indicate  an  examination  into  the  con- 
dition   of    the    prostate.      Vomiting,    too,    is 
often  caused  by  distention  of  the  bladder. 

It  should  be  borne  in  mind  that  stone  in 
the  bladder   may    be    the   primary   cause   in 

25 


GENITCMJKINAKy  TRACT. 


children  of  enuresis,  masturbation  or  prolap- 
sus recti. 

What  feels  at  the  other  end  of  the  searcher 
like  a  stone  in  the  bladder,  may  be  a  fold  of 
mucous  membrane  encrusted  with  urinary 
deposit. 

In  cases  of  suspected  rupture  of  the  blad- 
der, catheterization  is  not  always  a  sure  test. 
The  rent  may  be  so  large  that  the  catheter 
draws  away  urine  that  has  already  flowed 
into  the  peritoneal  cavity. 


Never  attempt  to  pack  a  bladder  for 
hemorrhage  without  the  aid  of  guy  sutures; 
with  them  one  can  make  absolutely  sure  that 
the  gauze  goes  into  the  bladder,  and  not  on 
top  of  it,  pushing  the  organ  away  from  the 
space  of  Retzius. 

To  prevent  a  suprapubic  or  other  drainage 
tube  from  becoming  displaced  is  easily  ac- 
complished by  fitting  another  tube  over  it 
like  a  collar;  this  outer  tube  is  split  through 
half  its  length  and  the  two  portions  are 
spread  out  over  the  skin  and  fastened  down 
with  adhesive  plaster. 


26 


GENITOURINARY  TRACT. 


Before  employing  a  rubber  catheter  test 
its  resiliency.  If  it  is  brittle  or  cracked,  dis- 
card it.  Not  infrequently  a  rotten  catheter 
breaks  off  in  the  bladder  while,  of  course, 
a  rough  catheter  or  sound  may  play  havoc 
in  the  urethra. 

Unconscious  patients  should  be  catheter- 
ized  at  regular  intervals  of  about  eight  hours. 

An  acutely  distended  bladder  should  not  be 
completely  emptied  in  one  sitting.  Its  rapid 
collapse   may   produce    hemorrhagic    cystitis. 


Force  is  never  helpful  in  overcoming  the  Penis. 
resistance  of  a  stricture  to  instrumental  pas- 
sage; it  is  bound  to  do  harm.  A  combina- 
tion of  patience  and  hot  applications,  with 
a  strong  admixture  of  gentleness  and  judg- 
ment, will  effect  the  desired  result  in  most 
cases. 

One  death  from  urethral  sepsis  is  enough 
to  impress  upon  one  the  importance  of  the 
teaching  that  perineal  drainage  should  always 
be  employed  after  internal  urethrotomy  three 
or  more  inches  from  the  meatus. 

Avoid   the   temptation   to   employ   a   con- 

27 


GENITOURINARY  TRACT. 


strictor  upon  the  penis  when  performing  cir- 
cumcision, etc.  It  may  cause  sloughing,  or 
actual   gangrene. 

After  circumcision  it  is  important  to  pre- 
vent adhesion  of  the  reflected  mucous  fold 
of  the  prepuce  to  the  corona  glandis,  by  the 
daily  passage  of  a  probe  about  the  corona, 
and  by  the  use  of  vaselin. 

Absorbent  cotton,  so  commonly  used  to 
catch  the  discharge  of  gonorrhea,  is  very 
inelegant.  It  sticks  to  the  glans,  allows  the 
meatus  to  glue  together,  and  is  difficult  to 
remove  without  soiling  the  fingers.  The 
following  is  the  cleanliest  and  most  surgical 
dressing.  In  a  six  inch  square  of  surgical 
gauze,  of  about  four  thicknesses,  cut  a  slit 
in  the  middle  just  large  enough  to  be  passed 
over  the  glans  and  to  be  held  behind  the 
corona.  Then  simply  draw  the  foreskin  for- 
ward. Indeed,  such  a  dressing  will  hold 
even  if  the  patient  has  been  circumcised,  if 
the  slit  in  the  gauze  is  not  too  large.  With 
such  a  simple  dressing,  there  is  no  retention 
of  the  pus,  no  irritation  from  contact  with 
the  secretions,  the  organ  is  readily  inspected 
and  the  gauze  is  easily  drawn  off  by  a  little 
pull  at  one  of  its  clean  corners. 


28 


GENITOURINARY  TRACT. 


A  comforting  support  for  the  testicles, 
when  a  patient  is  confined  to  bed  with  or- 
chitis, is  easily  furnished  by  a  well-padded 
cigar  box  cover,  grooved  to  fit  under  the 
scrotum,  and  laid  across  the  thighs.  Ad- 
hesive plaster  may  be  used  in  the  same 
manner. 


Scrotum 

and 

Testicle 


In  hydrocele  the  base  of  the  tumor  is  be- 
low, in  spermatocele  it  is  usually  above.  A 
milky  fluid  obtained  by  aspiration  usually 
speaks  for  spermatocele. 

If  a  cystic  swelling  in  the  scrotum  is 
opaque  when  examined  by  the  well-known 
transillumination  test,  especially  if  a  history 
of  traumatism  is  elicited,  it  may  still  be  a 
hydrocele.  Admixture  of  blood  in  the  hy- 
drocele  destroys   its  translucency. 

If  a  male  patient  with  supposed  strangu- 
lated hernia  complains  of  pain  running  down 
the  inner  aspect  of  the  thigh  it  is  well  to 
think  of  torsion  of  the  testicle. 

Accumulated  experience  shows  that  cas- 
tration alone  will  not  cure  the  great  ma- 
jority of  cases  of  tuberculosis  testis.  In 
many,   if   not   most,   cases   the  vas   deferens, 


29 


GENITOURINARY  TRACT. 


seminal  vesicle  or  prostate  is  involved,  and 
it  will  be  necessary  to  remove  one  or  more 
of  these  structures  in  order  to  cure. 

In  excising  a  varicocele  under  local  anes- 
thesia, tie  the  upper  ligature  first;  the  pain 
of  tying  the  lower  ligature  will  then  be  abol- 
ished. 

After  the  open  operation  for  varicocele 
the  scrotum  may  be  shortened  by  simply 
sewing  the  wound  together  transversely  in- 
stead   of    longitudinally. 


GYNECOLO= 
GICAL. 


It  is  a  good  rule  to  always  inspect  the 
labia  before  making  a  vaginal  examination. 
Many  pathological  conditions  in  these  parts 
may  otherwise  pass  unsuspected. 

Don't  be  tempted  to  exclude  gonorrhea 
because  you  see  no  bacterial  or  other  evi- 
dence of  vaginal  or  urethral  infection.  In 
women  the  presence  of  gonorrhea  may  not 
make  itself  known  for  six  weeks  or  more, 
and  salpingitis  may  be  the  first  evidence. 

Simple  incision  is  not  sufficient  in  the  treat- 
ment of  Bartholinian  abscesses.  They  should 
be  cauterized  daily  with  iodin,  and  if  they 
recur,   excised. 

30 


GYNECOLOGICAL. 


In  the  early  months  of  pregnancy  exami- 
nations should  be  made  to  determine  that 
there  is  no  retroversion,  or  to  treat  it  if  it 
exists.  A  retro  verted  gravid  uterus  impact- 
ed in  the  curve  of  the  sacrum  always  aborts. 

Ascites  in  the  presence  of  a  mass  in  the 
pelvis  usually,  but  not  necessarily,  means 
malignancy. 

Avoid  introducing  a  uterine  sound  in  ex- 
aminations when  pelvic  inflammation  is 
suspected.     It  may  set  up   a  parametritis. 

Impaction  of  feces  in  the  sigmoid  and 
rectum,  with  absorption  symptoms,  may 
simulate  pelvic  peritonitis. 

When  cleansing  the  vagina  and  vulva  in 
preparation  for  an  operation,  a  soft  cotton 
mop  should  be  used  for  the  vestibule;  a 
stiff  brush  is  too  apt  to  bruise  or  lacerate 
the  urethra  and  cause  dysuria  for  some  days 
thereafter. 

Before  performing  curettage  always  make 
a  final  bimanual  examination  of  the  uterus 
in  narcosis.  The  finding  may  determine 
some  other  form  of  treatment.     Again,  after 


3i 


GYNECOLOGICAL. 


curettage,  before  allowing  the  patient  to  get 
out  of  bed,  carefully  examine  the  pelvis  for 
signs  of  a  possible  exudate. 

As  a  final  cleansing  step  after  curettage^ 
of  the  uterus  it  is  well  to  introduce,  and  at 
once  withdraw,  a  packing  of  gauze.  This 
brings  out  with  it  fragments  of  tissue  not 
washed  out  by  the  irrigation. 

Sudden  collapse  after  a  curettage  for  sup- 
posed abortion  may  mean  the  rupture  of  an 
unsuspected  ectopic  gestation  sac. 

In  pulling  on  the  round  ligaments  in  the 
Alexander  operation,  use  the  fingers  rather 
than  instruments;  a  surer  hold  is  given,  one 
can  gauge  the  proper  force  to  employ  more 
readily,  and  there  is  less  likelihood  of  the 
ligaments   tearing. 

EXTREME  Lymph-edema  of  the  lower  extremity  as- 

nrip&  sociated  with  a  swelling  in  the  groin   (fluct- 

uating or  not)  is  significant  of  carcinoma  of 
the  inguinal  glands.  The  primary  lesion  may 
be  in  the  rectum,  e.  g.,  an  epithelioma  of  the 
anus  that  is  giving  no  symptoms. 

Do  not  consider  too  lightly  a  history  of 
"growing   pains"   in   the  extremities  in   chil- 

32 


EATBEHITIES. 


dren.     These   symptoms   may   be   due    to   a 
grave   osteomyelitis. 

The  presence  of  sciatica  demands  a  care- 
ful exploration  of  the  pelvis  by  rectal  or 
vaginal  examination.  It  should  also  be  re- 
membered that  Osier  described  sciatica  as 
one  of  the  early  symptoms  of  cancer  of  the 
breast. 

The  following  are  some  of  the  conditions 
in  the  presence  of  which  an  examination 
for  tabes  dorsalis  should  never  be  omitted: 
1 .  All  primary  swellings  of  the  knee  or  ankle 
joint  without  apparent  origin.  2.  "Sciat- 
ica" and  "lumbago."  3.  A  deep  ulcer  on 
the  base  of  the  great  toe.  4.  Repeated 
vomiting  at  various  intervals,  with  periods 
of  well-being  intervening.  5.  Abdominal 
pains  without  other  evident  cause. 

Pain  in  the  leg  after  an  abdominal  opera- 
tion often  means  the  development  of  a  fe- 
moral vein  thrombosis.  This  occurs  usually 
the  left  side. 

Congenital  paralysis  of  the  lower  limbs 
may  arise  from  an  internal  sacral  or  coccy- 
geal spina   bifida.      In   such   cases  rectal   ex- 


33 


EXTREMITIES 


animation  reveals  the  trouble  and  an  opera- 
tion may  afford  marked  improvement  or 
even   a  brilliant  cure. 

Never  advise  an  elastic  stocking  in  cases 
of  varicose  veins  where  recent  phlebitis  exists. 
The  pressure  may  detach  a  part  or  whole  of 
the  thrombus,  propelling  it  into  the  general 
circulation. 

When  performing  amputation,  arthrec- 
tomy,  osteotomy  or  similar  operation  it  is 
wiser  to  leave  the  constrictor  in  place  until 
the  dressing  is  partly,  or  entirely,  applied, 
than  to  remove  it  after  tying  the  large  ves- 
sels, in  an  effort  to  secure  the  small  ones.  In 
the  former  case  the  snugly  applied  dressing 
will  safely  prevent  hemorrhage;  in  the  latter 
case,  there  may  be  an  alarming  loss  of  blood 
from  the  numerous  small  vessels  in  the  very 
time  the  efforts  are  made  to  tie  them  all. 

Do  not  amputate  an  extremity  for  sar- 
coma without  a  previous  careful  examina- 
tion of  the  lungs  and  mediastinum  for  me- 
tastasis. Such  symptoms  as  continued 
cough,  a  small  hemoptysis  or  beginning  dysp- 
nea, should  be  regarded  as  highly  sugges- 
tive of  such  a  complication. 


34 


EATRENITIE5. 


After  major  amputations  an  elastic  con- 
strictor should  always  be  left  at  the  head  of 
the  bed,  so  that  the  nurse  can  immediately 
apply  it  in   case  of  secondary  hemorrhage. 

Inflamed  areas  and  abscesses  about  the 
knees  of  creeping  infants  should  be  exam- 
ined for  foreign  bodies. 

Punctured  wounds  about  the  knee  should 
be  treated  with  the  greatest  solicitude  and 
attention  to  asepsis,  in  order  to  prevent  in- 
fection  of  the  joint. 

In  operating  for  loose  bodies  within  the 
knee  joint,  do  not  be  satisfied  with  removing 
but  one  body;  a  careful  examination  should 
be  made  to  determine  the  presence  of  more, 
for  they  are  very  frequently  multiple. 

Pulsation  in  the  course  of  an  artery 
should  not  lead  to  the  hasty  conclusion  that 
one  is  dealing  with  an  aneurism.  A  tumor 
overlying  a  large  vessel,  and  also  a  vascular 
sarcoma  of  the  bone,  may  simulate  an  aneu- 
rism very   closely. 

Never  incise  a  swelling  in  the  course  of  a 
large  artery  without  making  sure  first  that 
it  is  not  an  aneurism. 


35 


EXTREMITIES. 


When  clamping  a  vein  in  continuity  se- 
cure the  proximal  end  first;  otherwise  it  will 
empty  and  may  become  lost  to  view. 

Tenderness  in  the  heel,  or  pain  and  ten- 
Foot,  derness  in  the  sole  of  the  foot  is  very  often, 
indeed,  of  gonorrheal  origin.  It  will  not 
be  relieved  in  such  cases  until  treated  on 
that  basis.  The  patient  may  deny  that  he 
ever  had  gonorrhea.  Examine  his  urine; 
shreds  tell  their  own  story. 

Do  not  be  too  hasty  in     ascribing     the 

cause  of  pain     in  the     tendo    Achilles,  or 

Achilles   bursa,   to  an   ill-fitting   shoe.     First 

exclude  gonorrheal  infection. 

If  the  cause  of  pain  in  the  feet  is  not  other- 
wise clear,  examine  them  in  the  dependent 
position.  This  may  develop  the  presence 
of  erythromelalgia. 

The  determination  of  the  presence  of  a 
fracture  of  one  of  the  mid-tarsal  bones,  is 
extremely  difficult,  and  usually  impossible, 
without  x-ray  examinations.  Yet  these  ex- 
aminations have  shown  the  occurrence  of 
such  fractures,  alone,  or  associated  with  in- 
juries to  other  bones,  as  the  result  of  injuries 

36 


EXTREMITIES. 


by  slight  or  severe  direct  violence.  For 
this  reason,  and  because  fractures  of  the 
metatarsals  by  indirect  violence  are  by  no 
means  uncommon,  it  should  be  practically 
a  routine  to  submit  the  foot  to  skilful  skiag- 
raphy in  all  cases  where  either  form  of  vio- 
lence may  have  occurred.  It  will  save  many 
patients  from  weeks  of  suffering  and  disa- 
bility. In  this  region,  more  than  in  any 
other,  the  x-rays  are  a  means  of  diagnosis 
that  cannot  be  dispensed  with. 

Many,  at  least,  of  the  sprains  of  the  an- 
kle involve  a  fracture  of  the  tip  of  the  mal- 
leolus, and  should  be  treated  by  immobili- 
zation  in  plaster-of -Paris. 

In  old  people,  as  in  diabetics,  corns, 
bunions  and  wounds  of  the  feet  demand 
the  most  careful  attention.  They  are  often 
the  starting  points  of  gangrene. 

A  very  simple  method  of  curing  a  corn  is 
to  excise  it. 

A  useful  method  of  treating  mild  grades 
of  ingrowing  toe-nail  consists  in  pulling  the 
flesh  away  from  the  nail  with  a  strip  of  adhe- 
sive  plaster,    disinfecting   the    space   between 


37 


EXTRENITIES. 


flesh  and  nail  and  packing  it  with  a  bit  of 
gauze.  The  gauze  may  be  run  under  the 
edge  of  the  nail,  which,  in  addition,  may  be 
trimmed  away  from  the  flesh. 

Remember    that    chronic    ulcers    on  the 

Hand,  hands  are  found  in  brass  workers,   and  that 

a  discontinuance  of  this  occupation  is  nec- 
essary  to   secure  healing. 

The  best  drainage  should  be  afforded  for 
all  punctured  wounds  of  the  palm;  suppura- 
tions in  this  region  are  very  disagreeable  and 
are   followed   by  severe   consequences. 

In  dealing  with  infections  of  the  hand 
bear  in  mind  that  under  a  simple  bleb  may 
lie  an  extensive  phlegmon,  threatening,  or 
actually  involving,  a  tendon  or  bone  and  ur- 
gently needing  a  generous  but  wisely  placed 
incision;  while  on  the  other  hand,  a  tendon 
may  be  thrust  from  its  protecting  sheath 
into  the  area  of  destruction  by  a  knife  sweep 
more  earnest  than  judicious.  A  crater-like 
opening  in  a  sodden  skin,  though  freely  dis- 
charging pus,  may  need  enlarging  to  protect 
the  tissues  underlying;  while  another  open- 
ing, too  long  continued  by  unnecessary  pack- 
ing, may  cripple  a  joint  or  tendon  by  undue 
cicatrization. 

38 


EXTREMITIES. 


Indolent  sinuses,  as  of  the  fingers  after 
deep  infections,  frequently  heal  by  the  daily 
use  of  prolonged  immersions  in  hot  water. 

In  dealing  with  infections  or  injuries  of 
the  fingers  amputation  should  be  a  dernier 
resort.  This  is  especially  the  case  with  a 
thumb,  the  most  important  of  all  the  fingers. 

In  a  case  of  fresh  traumatic  amputation 
of  a  part  of  the  finger,  if  the  amputated  part 
has  not  been  too  lacerated  or  crushed,  try 
to  restore  the  member  by  cleansing  the  parts 
carefully  and  suturing  it  to  the  stump. 
Once  in  a  while  the  graft  will  "take." 

When  exploring  for  a  needle  or  other  for- 
eign body  the  finger  tip  is  often  far  more  use- 
ful than  a  probe.  It  must  be  remembered, 
too,  that  strands  of  fascia  often  impart  to  a 
probe  "the  feel"  of  a  foreign  body.  Cut- 
ting and  picking  at  these  deceptive  strands 
of  tissue  soon  distort  the  field  of  operation 
and  destroy  important  relations.  It  is  ex- 
tremely desirable  to  conduct  a  systematic 
and  cleanly  dissection  when  seeking  a  for- 
eign body. 

Very    often    the   unskilful   treatment   of    a     pKACTUKES. 
fracture  is  worse   than   no   treatment   at   all. 

39 


FRACTURES. 


Serious  deformities  may  result  from  the  ne- 
glect of  small  details  no  less  than  from  the 
violation  of  important  principles. 

The  important  considerations  in  the  treat- 
ment of  fractures  are,  at  first,  relief  of  pain 
and  reduction  of  swelling,  and,  subsequently, 
preservation  of  function  of  the  muscles,  the 
nerves  and  the  neighboring  joints.  Thus 
there  have  come  into  modern  methods  a  rec- 
ognition of  the  value  of  early  and  fre- 
quent massage  and  passive  motion  (and  in 
suitable  cases,  of  active  motion)  and  of  the 
necessity  for  avoiding  splints  that  unduly 
compress  the  muscles  or  deprive  them  of 
activity. 

In  the  treatment  of  fractures  of  the  fore- 
arm no  consideration  is  more  important  than 
the  avoidance  of  contractures  of  the  fingers, 
by  the  intelligent  use  of  splints  and  by 
means  of  early,  active  and  passive  move- 
ments. 

Permanent  contracture  of  the  muscles,  not- 
ably of  the  flexor  group  in  the  forearm,  may 
develop  within  a  very  short  time  after  the 
application  of  a  splint  that  exercises  undue 
compression.  It  is  a  wise  rule  to  inspect  all 
fracture   dressings   within   twenty -four  hours; 


40 


FRACTURES. 


and  when  this  is  not  expedient  special  care 
should  be  exercised,  when  applying  the 
dressing,  to  avoid  compression. 

In  very  many  cases  it  is  not  necessary  to  the 
diagnosis  of  fracture  to  elicit  crepitus  and 
abnormal  mobility — often  painful  manipu- 
lations. In  several  forms  of  fracture  there 
are  other  positive  diagnostic  evidences. 
Thus,  with  Colle's  fracture  the  level  of  the 
styloid  of  the  radius  will  almost  always  be 
found  to  have  receded  from  beyond  that  of 
the  styloid  of  the  ulna.  Moreover,  x-ray 
examinations  save  much  painful  manipula- 
tion. 

In  all  examinations  of  children,  and  in  the 
examination  of  adults  for  suspected  fractures, 
leave   the  painful  manipulations  for  the  last. 

The  x-rays  have  taught  us  that  mathemati- 
cal reduction  is  rarely,  and  even  linear  re- 
duction is  seldom,  accomplished  even  in 
cases  in  which  excellent  functional  results 
are  secured.  Radiographs  have  thus  fre- 
quently been  made  the  basis  of  blackmail- 
ing damage  suits.  Nevertheless  the  x-rays 
are,  of  course,  of  immense  value  in  the 
treatment    of    fractures — not   only    for    refer- 


41 


FRACTURES. 


ence  before  and  after  reduction,   but  during 
the  reduction  itself. 

A  fracture  produced  by  only  slight  vio-^ 
lence  should  at  once  raise  the  suspicion  of 
a  malignant  growth.  In  such  a  case  a  uni- 
form dark  shadow  about  the  bone  as  seen 
in  the  fluoroscope  is  to  be  interpreted  as  a 
neoplasm  rather  than  as  callus,  for  recent 
callus  is  not  opaque  to  the  x-rays. 

If  a  small  child  has  been  pulled  by  the 
arm  and  thereafter  has  disability  in  that 
member,  attention  should  first  be  directed  to 
the  upper  end  of  the  radius.  Here  one  is 
apt  to  find  a  subluxation  of  the  head  of  the 
bone  ("pulled  arm")  or  an  epiphyseal  sepa- 
ration. 

In  the  aged  pain  and  disability  in  the  arm 
after  traumatism  demand  especial  care  in 
examination  of  the  shoulder.  Fracture  of  the 
head  of  the  humerus  is  often  overlooked. 

It  must  be  remembered  that  fractures  of 
the  metatarsal  bones  may  be  produced  by 
slight  injuries.  Thus,  the  base  of  the  fifth 
metatarsal  may  be  fractured  by  a  twist  of 
the  foot  while  walking  or  dancing. 


42 


TRACTURES. 


In  cases  of  fracture  where  an  end  of  the 
bone  lies  close  beneath  the  skin  do  not  place 
a  pad  or  any  pressure  whatever  over  this 
point. 

When  applying  a  plaster  dressing  to  the 
leg  always  include  the  foot  if  the  patient  is 
to  be  confined  to  bed;  otherwise  "drop 
foot"   will  develop. 

A  padded  triangular  wooden  or  card- 
board splint — one  leg  of  the  triangle  band- 
aged to  the  thigh,  and  another  to  the  trunk 
— makes  an  excellent  ambulatory  apparatus 
in  the  treatment  of  fractures  of  the  shaft  of 
the  femur  in  small  children.  It  maintains  re- 
duction, leaves  the  leg  free  and  does  not  in- 
terfere with  keeping  the  child  clean.  Card- 
board splints  can  be  best  molded  to  an  ex- 
tremity by  tearing,  instead  of  cutting  them. 

Exposure  to  the  x-rays  causes  atrophy  of  SKIN 

the  sweat  glands;  radiotherapy  is  proving 
the  most  satisfactory  treatment  for  hyperi- 
drosis. 

Pure  nitric  acid,  applied  on  the  narrow, 
blunt  tip  of  a  glass  rod  is  successful  in  the 
complete  destruction  of  verruccae,  but  only 
if  it  is  forced  down  into  their  very  roots. 

43 


SKIN. 


Localized,  indurated  or  softening  skin  in- 
fections ("boils")  often  disappear  com- 
pletely or  open  painlessly  under  an  applica- 
tion of  emplastrum  plumbi  in  which  is  in- 
corporated 10  per  cent,  of  salicylic  acid,  or 
of  10  per  cent,  to  20  per  cent,  salicylated 
soap  plaster.  After  the  boil  opens  the  tiny 
dressing  should  be  changed  every  two  or 
three  hours. 


When  shaving  the  hair  in  the  neighbor- 
hood of  a  boil,  draw  the  razor  from  the  base 
to  the  apex  so  as  not  to  drive  microorganisms 
deeper  into  the  tissues. 

WOUNDS.  If  an  incised  wound  in  the  soft  parts  does 

not  heal  as  readily  as  it  should,  examine  the 
urine   for   sugar. 

In  wounds  made  by  coal  on  the  exposed 
parts  of  the  body,  remove  all  the  particles 
of  coal  dust;  otherwise  a  disfiguring  pig- 
mentation might  follow. 

A  broad  clean  ulcer  on  the  soft  parts 
often  heals  per  primam  if  its  surface  is 
swabbed  with  iodin  and  its  edges  then 
brought  together  with  adhesive  straps. 


44 


WOUNDS. 


The  appearance  of  emphysema  in  the  tis- 
sues about  an  infected  wound,  accompanied 
by  fever  and  escape,  of  bubbles  of  gas  from 
the  wound,  should  be  regarded  as  very  omi- 
nous, and  indicative  of  gas  bacillus  infection. 
Such  cases  should  be  treated  by  extensive  in- 
cisions. 

Blank  cartridge  wounds  must  be  laid  wide 
open,  all  dirt  and  wad  carefully  removed, 
and  the  area  swabbed  out  with  tincture  of 
iodin,  or  with  pure  carbolic  acid  followed 
by  alcohol. 


Soft  tumors  under  the  skin,  disappearing 
in  the  recumbent  posture,  are  usually  lym- 
phangiomata. 


TUPIORS. 


If  a  swelling  is  "fluctuating"  do  not  be 
too  sure  that  it  is  not  a  solid  growth.  Lym- 
phangiomata  fluctuate. 

A  subcutaneous  tumor  with  a  history  of 
puncture  or  the  presence  of  a  minute  scar 
in  the  overlying  skin,  usually  means  that  one 
is  dealing  with  an  inclusion-  or  so-called 
Ranvier  cyst. 

In    hard     swellings     of     doubtful     nature 


45 


TUNOR5. 


marked  tenderness  is  significant  of  actin- 
omycosis, when  acute  inflammation  may  be 
excluded. 

Do  not  give  a  good  prognosis  in  cases  of 
melanosarcoma  of  the  fingers  or  toes,  no 
matter  how  small  the  tumor  may  be,  and  no 
matter  how  high  the  amputation  is  per- 
formed. In  the  majority  of  cases,  these  pa- 
tients succumb  to  metastases. 

In  the  presence  of  a  pulsating  tumor,  es- 
pecially of  the  bone,  examine  the  kidneys. 
Secondary  hypernephromata  always    pulsate. 

The  "egg  shell  crackle"  of  certain  bone 
tumors  is  characteristic  of  multiple  myeloma. 
Examine  the  urine  for  albumose. 

In  cases  of  bone  tumor  there  are  three  or- 
gans which  should  never  be  overlooked  in 
seeking  a  primary  growth — the  thyroid,  pro- 
state and  mammary  glands. 

An  amputation  for  malignant  ulceration 
should  not  be  performed  until  the  possibility 
of  its  being  merely  a  broken-down  gumma 
has   been   satisfactorily   excluded. 

46 


TUBERCULOSIS. 


Individuals  with  bluish  sclerotics,  and  with 
dark  lanugo  over  the  upper  part  of  the  back, 
are  usually  of  tuberculous  diathesis;  and 
these  signs  are  not  inconsequential  in  mak- 
ing a  diagnosis. 

Surgical  tuberculosis,  no  less  than  pul- 
monary tuberculosis,  calls  for  the  most  care- 
ful general  treatment,  post-operative  and 
otherwise. 

The  temptation  should  not  be  yielded  to 
to  incise  a  psoas,  hip  or  other  "cold"  ab- 
scess, except  in  isolated  instances  and  then 
only  under  the  most  rigid  asepsis.  The  pro- 
duction of  a  mixed  infection  means  chronic 
sinus,  chronic  invalidism  and,  often,  amy- 
loid disease. 

In  operations  upon  the  head  or  neck  the  ANESTHESIA 
anesthetist  must  see  to  it  that  no  instrument 
is  allowed  to  lie  over  the  cornea,  especially  if 
it  is  exposed.       Ulceration    may    be    caused 
with  ease;  it  is  often  healed  with  difficulty. 

During  narcosis,  when  stertorous  breath- 
ing calls  for  extension  of  the  jaw,  it  is  well 
to  hold  it  forward  first  on  one  side,  then  on 
the  other,  alternating  at  short  intervals.  Long 

47 


ANESTHESIA. 


continued  pressure  at  the  angle  or  angles  of 
the  jaw  produces  much  soreness.  Often  the 
jaw  can  be  kept  forward  by  catching  the 
lower  incisor  teeth  in  front  of  the  upper 
ones  (if  they  are  strong)  ;  a  single  finger  or 
the  chin  is  enough  to  maintain  this  position. 

Whenever  the  arrangement  of  a  patient 
upon  the  operating  table  requires  an  extrem- 
ity to  occupy  a  constrained  position,  that  po- 
sition should  be  shifted  from  time  to  time 
to  avoid  pressure  paralysis.  The  anesthetist 
should  never  draw  the  arms  alongside  the 
head,  nor  permit  the  strap  of  a  leg-holder 
to  press,  for  more  than  a  few  minutes  at  a 
time,   upon  the  brachial  plexus  in  the  neck. 

Nitrous  oxid  narcosis  can,  in  most  cases, 
be  continued  "smoothly,"  with  no  cyanosis 
and  with  fair  degree  of  relaxation,  even  for 
an  hour.  A  laparotomy  may  thus  be  per- 
formed, if  ether  and  chloroform  are  con- 
traindicated.  To  secure  such  a  narcosis  it 
is  best  to  use  an  apparatus  that  permits  ex- 
halation into  the  gas  bag,  and  which  has  a 
valve  for  the  admission  of  air.  The  bag 
should  not  be  distended  fully.  After  brief 
air  and  gas  administrations,  air  is  turned  off 
and  the  patient  breathes  N2O  and  his  own 
CO2.      At    short     intervals,     and     whenever 


48 


ANESTHESIA. 


there  is  any  cyanosis,  a  single  breath  of  pure 
air  is  allowed. 

Local  anesthetics  cannot  be  injected 
painlessly  into  tense,  inflamed  areas  unless 
the  injection  is  begun  at  a  point  in  the  skin 
well  beyond  the  seat  of  inflammation. 

For  a  single  intravenous  infusion,  as  to  INFUSIONS 
combat  the  shock  of  hemorrhage,  it  is  not 
essential  that  the  solution  contain  any  of  the 
blood  salts  but  the  most  abundant  one — 
sodium  chlorid.  For  repeated  infusions, 
however,  as  sometimes  used  in  treating  vari- 
ous toxemias,  it  is  better  to  employ  also  the 
other  salts,  the  solution  being  made  of  so- 
dium chlorid  0.9,  potassium  chlorid  0.03, 
calcium  chlorid  0.02,  water  1  00. 

Intravenous  saline  infusions  in  too  large 
volume  are  harmful  by  the  production  of 
congestion  of  the  internal  viscera.  One  to 
one  and  a  half  pints  are  enough  for  an  adult 
of  average  weight. 

In  performing  subcutaneous  infusion  do 
not  allow  too  much  fluid  to  accumulate  at 
one  area,  otherwise  necrosis  may  occur. 
Shift   the   needle   to   various    parts    not    by 

49 


INFUSIONS. 


swinging  it  from  side  to  side,  but  by  partly 
withdrawing  it  and  reinserting  it  to  another 
area. 


POST= 
OPERATIVE. 


The  pain  in  the  lower  part  of  the  back^ 
that  is  so  frequently  complained  of  after 
operation,  can  be  best  relieved  by  placing  a 
small  pillow  in  the  hollow  of  the  spine. 


In  determining  the  cause  of  a  post-opera- 
tive fever  never  fail  to  look  at  the  throat. 

If,  after  a  period  of  post-operative  cathe- 
terization, the  patient  finds  herself  unable  to 
pass  urine  spontaneously,  apply  hot  towels 
to  the  vulva. 

Gastric  lavage  is  the  best  post-operative 
anti-emetic. 


INSTRU= 
HENTS. 


Vomiting  may  frequently  be  controlled 
by  one-drop  doses  of  tincture  of  iodin  in 
water  at  half-hourly  intervals. 

Aluminum  instruments  should  not  be 
boiled  in  soda  solution,  like  other  instruments. 
They  are  to  be  sterilized  by  boiling  in 
plain  water  or  by  passing  them  through  an 
alcohol  or  Bunsen  flame. 


50 


INSTRUMENTS. 


Warming  a  laryngeal  mirror  prevents  con- 
densation of  the  breath  upon  it  for  only  a 
short  time.  The  mirror  will  remain  bright, 
however,  throughout  a  prolonged  examina- 
tion if,  instead  of  warming  it,  its  surface  is 
smeared  with  an  invisible  film  of  soap. 

The  use  of  an  "invalid  table,"  the  shelf 
of  which  projects  over  the  patient's  body, 
will  be  found  a  great  convenience  during 
operations  as  a  receptacle  for  instruments  in 
immediate  use.  It  saves  time  and  temper, 
and  avoids  accumulation  of  instruments  on 
the  patient's  body. 

When  scissors  become  "catchy"  their 
edges  can  often  be  surprisingly  smoothed  by 
carrying  each  blade  repeatedly  from  lock  to 
tip  between  the  firmly  pressing  thumb  and 
forefinger.  Each  kind  and  size  of  scissors 
has  its  own  capacity,  and  should  be  used 
only  for  what  it  is  intended.  Ophthalmic  in- 
struments are  not  intended  for  ordinary  dis- 
sections, tissue  scissors  should  not  be  used  for 
cutting  bandages,  nor  bandage  scissors  for 
plaster-of-Paris. 

A  scroll-saw,  with  an  assortment  of  a 
dozen  saws,  can  be  purchased  at  the  hard- 
ware store   for  twenty-five  cents;  it  is  ideal 


5i 


INSTRUMENTS. 


for  resection  of  the  small  bones  of  the  hand 
and  foot,  for  amputations  of  the  digits,  etc. 

Well  tempered  carpenter's  chisels  and 
gouges,  and  a  carpenter's  wooden  mallet 
answer  the  purpose  admirably  for  bone  work. 
A  useful  bone  drill  can  also  be  selected  from 
the  stock  of  the  hardware  dealer. 

A  gardener's  pruning  knife  and  a  car- 
penter's miter  saw  are  the  best  tools  for  the 
removal  of  plaster  dressings. 

A  cheap  potato  knife,  rough  sharpened 
on  a  stone,  is  excellent  for  cutting  through 
starch  bandages. 

Crochet  needles  are  most  useful  for  lifting 
buried  stitches  out  of  a  sinus. 

Knitting  needles  find  another  purpose  as 
a  means  of  rupturing  the  membranes  when 
this  is  needed  in  obstetrical  work. 

Sharp  and  blunt  retractors  may  be  fash- 
ioned, in  an  emergency,  by  bending  the  tines 
of  a  fork  and  the  handle  of  a  spoon,  respec- 
tively. 


52 


INSTRUMENTS. 


A  teaspoon  is  also  useful  as  an  elevator  of 
the  eye,  when  resection  of  the  superior  maxilla 
is  performed. 

An  inverted  tea-strainer  is  useful  in  the 
dressing  after  colostomy,  to  prevent  pressure 
of  the  gauze  upon  the  gut. 

A  spoon-shaped  potato  cutter  may  be 
used,  in  an  emergency,  as  a  wound  curette. 

The  multiple  surgical  uses  of  the  hairpin 
are  also  well-known.  Of  stouter  material,  if 
necessary,  a  small  self-retaining  retractor 
can  be  quickly  made  from  steel  wire;  it 
often  obviates  the  need  of  an  assistant  when 
searching  the  hand  or  foot  for  a  foreign  body. 

Similarly,  applicators,  probes  and  de- 
pressors may  be  improvised  by  twisting  stout 
copper  wire. 

A  wedge  of  hard  wood  makes  a  gag 
quite  useful,  often,  when  administering 
anesthesia. 

A  discarded  thermometer  case  (or  a  hard 
rubber  douche  point)  is  a  serviceable  handle 
in  which  to  mount,  with  candle  grease  or  ad- 
hesive plaster,  a  stick  of  silver  nitrate. 


53 


INSTRUMENTS. 

Cheap  powder  blowers,  such  as  are  used 
for  insecticides,  may  be  employed  as  insuf- 
flators in  surgical  work,  and  pepper  boxes  are 
useful  for  dusting  powders. 

Steel  spring  tape-measures  are  better  than 
the  wires  generally  sold  for  the  purpose,  for 
conducting  to  an  x-ray  tube  the  current  from 
the  coil  or  static  machine;  easily  kept  taut, 
and  quickly  adjusted,  they  are  safest  for  the 
patient  and  most  convenient  for  the  operator; 
that  they  are  not  insulated  is  inconsequential 
— the  coverings  on  the  regular  wires  do  not 
insulate  the  induced  current. 

Wooden  skewers  are  serviceable  nail- 
cleaners.  Rolling  pins  and  kitchen  towel 
racks  are  very  convenient  for  adhesive  plaster, 
rubber  tissue,  etc.,  especially  for  hospital 
dressings. 

Tar-paper  is  a  smooth,  fairly  waterproof 
material  to  tack  on  the  floor  when  preparing 
a  room  for  operation. 

The  threading  of  catgut  or  kangaroo  ten- 

oUTUREo.         don    through    a    needle-eye  not  very  roomy 

may  be  made  easy  by  cutting  the  suture  end 

obliquely  and  flattening  it  between  the  han- 

54 


SUTURES. 


dies  of  the  scissors.  Silk  must  not  be  cut 
obliquely,  however,  for  this  makes  it  apt  to 
unravel  while  it  is  being  threaded. 

Silkworm-gut  is  easily  dyed,  and  inciden- 
tally impregnated  with  an  antiseptic,  by  im- 
mersing it  for  twenty-four  hours  in  one  per 
cent,  solution  of  methyl  violet,  before  the 
boiling. 

When  suturing  a  wound  of  the  scrotum, 
if  the  tissue  (dartos)  is  contracted,  apply  a 
warm  compress  for  a  moment  to  cause  re- 
laxation. 

Catgut  strands  do  not  make  a  good  drain 
for  wounds;  they  tend  to  swell  and  occlude. 

Grocers'  paper  bags  are  well-adapted  re- 
ceptacles for  soiled  dressings. 

When  a  "wet  dressing"  fails  to  properly 
drain  a  septic  wound  try  a  glycerin  dressing 
— gauze  wrung  out  in  pure  glycerin  and  cov- 
ered with  waterproof  material. 

Subiodid  of  bismuth  dusted  on  an  ooz- 
ing granulating  wound  promptly  stops  the 
bleeding.  It  is  also  an  excellent  stimulant 
to  the  growth  of  epithelium. 


DRESSINGS. 


55 


DRESSINGS. 


Gauze  is  preferable  to  cotton  for  padding 
the  axilla  or  breasts  in  dressings  that  are  not 
frequently  renewed.  Cotton  easily  becomes 
matted  with  sour-smelling  secretions  and  thus 
sets  up  dermatitis.  The  skin  over  the  tendo* 
Achilles  and  about  the  heel  cannot  be  too 
carefully  padded,  when  applying  Buck's  ex- 
tension apparatus. 


Collodion,  commonly  used  to  seal  a  punc- 
ture wound,  as  after  aspiration,  will  not  ad- 
here if  the  spot  is  wet  or  bleeding.  To  ob- 
viate this,  pinch  up  the  skin,  wipe  it  dry,  ap- 
ply the  collodion  and  continue  the  compres- 
sion a  minute  or  so  until  the  collodion  has 
begun  to  contract. 


When  rubber  tissue  is  not  at  hand  to  make 
a  "cigarette  drain,"  rubber  tubing  may  be 
used  in  its  place.  Split  a  piece  of  tubing  of 
appropriate  length,  and  lay  the  wick  of  gauze 
in  the  trough  thus  made.  Fenestrae  may  be 
cut  as  desired. 


The  painfulness  of  withdrawing  packings 
that  have  dried  in  a  wound  may  be  avoided 
by  soaking  them  with  peroxid  of  hydrogen. 


56 


DRESSINGS. 


A  urethral  endoscope  will  be  found  a 
great  help  as  a  means  of  introducing  a  rub- 
ber drainage  tube  into  a  narrow,  tortuous 
sinus. 

The  change  of  dressings  of  burns  may  be 
made  painless,  and  the  growth  of  epithelium 
encouraged,  by  employing  next  to  the  wound 
sterile  strips  of  gutta-percha  in  the  same  man- 
ner as  for  skin-grafts.  Subiodid  of  bismuth 
lightly  dusted  on  the  granulating  surface 
stimulates  epithelial  growth. 

Patients  will  appreciate  the  use  of  black 
bandages  for  the  scalp — where  they  are 
comparatively  inconspicuous,  and  for  the 
hands — where  they  do  not  soil. 

Mastoid  and  scalp  dressing  may  be  re- 
duced in  bulk,  and  the  uncomfortable  neck 
turns  of  the  bandage  avoided,  by  the  use  of 
starch  bandages,  which  hold  neatly  and 
firmly. 

Bandages  may  be  fastened  in  place  more 
neatly  and  more  securely  with  strips  of  ad- 
hesive plaster,  than  with  safety  pins.  When 
bandaging  a  finger  or  toe,   turns  about  the 


57 


DRESSINGS. 


hand  or  foot  will  be  unnecessary  if  the  dress- 
ing is  fastened  down  with  a  narrow  strip  of 
plaster  run  over  the  top  from  base  to  base, 
and  another  strip  circularly  about  the  dress- 
ing at  the  base  of  the  digit.  When  using 
black  bandages,  employ  black  adhesive 
plaster. 

Stains  of  anilin  dyes  may  be  removed 
from  the  fingers  with  strong  hydrochloric 
acid,  stains  of  iodin  with  aqua  ammonia, 
and  stains  by  silver  nitrate  with  potassium 
iodid  solution. 


53 


I N  D  E  X. 


PAGE. 


Abdomen        -------  14 

Anesthesia,          ------  47 

Bile  Tract,       -------  16 

Bladder, 25 

Breast, -         -  12 

Cranium,     --------  7 

Dressings,        -         -         -                                    -  55 

Ear,     --------  9 

Extremities,  -------  32 

Foot, 36 

Fractures,        --------  30 

Genito-Urinary  Tract,        -                  -         -  23 

Gynecological,       ------  30 

Hand,          -------  33 

Infusions,        -------  49 

Instruments,       -         -         -         -         -         -  50 

Intestines,       -------  18 

Kidney,       -         -         -         -         -         -         -  23 


11 


INDEX. — Continued. 


PAGE. 

Mouth,    -        -        -        -        -        -        -        -  8 

Neck,  -        -  10 

Nose,       -  -        -        -  7 

Penis,  ..-.-.-  27 

Post-operative,        -  -  5° 

Rectum,       -         -  -  -         -  20 

Scrotum,  -------  29 

Skin,  ..---.-  43 

Stomach,  -------  17 

Sutures,       -------  54 

Testicle,  -  -        -  29 

Thorax,        - 12 

Throat,  -  -  8 

Tuberculosis,      -  47 

Tumors,  -------  45 

Urinary  Tract,     ------  23 

Wounds,  -------  44 


^5 


<7  <5 


*^7    <2 


deft    I 


^^   //&  S7 


*H  y-%^  • 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD33B76C.1 

Surgical  suggestions:  practica  -".ev'  |e 


2002108674 


